MSK Flashcards
If someone present with severe back pain, usually around the thoracic area, and has a fever and respiratory symptoms, what is a likely diagnosis?
Pott’s disease of the spine
- secondary to TB infection
If a patient presents with a history of increasing back pain and fever, what should you suspect and how is it diagnosed and treated?
Dicitis
Diagnosis:
MRI
CT guided biopsy
Treatment:
6-8 weeks IV Antibiotics
+
Infective endocarditis scan
What back pathology typically presents with worsening of pain:
- in the morning
- extension movement
Facet Joint Pain
- straight leg test will be negative.
If a patient presents with fever and severe pain that is getting worse in their:
- lower back
- radiating into their thigh and groin
the patient finds the pain is relieved somewhat by lying down and flexing their legs.
What is a likely diagnosis?
Psoas Abscess
Primary: haematogenous spread from distant site
Secondary: spread from local sources: crohn’s, diverticulitis, GU infections, endocarditis
If there is a disc prolapse at level 4/5 which sensory root will be affected?
Dermatome 5
What is the general Management for lower back pain?
Analgesia
- NSAIDs
- Paracetamol
Muscle relaxants
- diazepam (if needed)
Early mobilization
Physiotherapy
Cognitive behaviour therapy
Which primary tumour will show a codman’s sign on x-ray?
Osteosarcoma
What disease may lead to osteosarcoma?
Paget’s disease
How is osteosarcoma diagnosed and what other place should be imaged? and how is it treated?
High resolution CT
Image the Chest - the cancer spreads to lungs early
Treatment:
- 8 weeks chemotherapy
- amputation
- continual chemotherapy
Where does osteosarcoma usually present?
Metaphysis of long bone
Which tumour may have the onion sign on xray?
Ewing’s sarcoma
Why should chondromas be removed?
They can become malignant and transform into chondrosarcomas
What is the management for chondrosarcomas?
Only surgical
What are some of the complications of Paget’s disease?
Pathological fractures
Hypercalcaemia
Nerve compression
Deafness
Osteosarcoma
What are the characteristic findings of the hands with OA?
Heberden’s nodes - DIPJ
Bouchard’s Nodes - PIPJ
Squaring of the base of thumb - CMJ
Weakened grip
What is the management for OA?
Lifestyle advice + strengthen exercises
physiotherapy
Analgesics:
1st line: Paracetamol + topical NSAIDs
2nd line: Oral NSAIDs + PPI
3rd Line: Opioids + steroid injections
What is the diagnostic criteria for OA?
Diagnosis can be made clinically if: >45 years old Signs and symptoms \+ No stiffness over 30mins in morning
What are some extra articular manifestations of RA?
Pulmonary fibrosis
Pulmonary nodules
pleurisy
Episcleritis
Scleritis
Corneal ulceration
Vasculitis
Nodules
Felty’s syndrome
Depression
What x-ray changes can be seen in Ankylosing Spondylitis?
Squaring of vertebral bodies
Subchondral sclerosis
Syndesmophytes
- ligament calcification
Subchondral erosion
Fusion
- facet joints
- sacroiliac joints
- costovertebral joints
What is the management of ankylosing spondylitis?
Physiotherapy
Smoking cessation
1st Line:
- NSAIDs
- naproxen
- steroids for flares
2nd line:
- TNA alpha inhibitors
3rd line:
- Secukinumab
- surgery
What is a IL-17 inhibitor used in ankylosing spondylitis?
Secukinumab
What are some complications of Ankylosing spondylitis?
Bamboo spine
Vertebral fractures
Lung fibrosis
- apex of lungs
Heart block
What is an important clinical test to be done for Ankylosing spondylitis that suggests severe restriction in the lower spine?
Schober’s test
This is when the L5 is marked, then 10cm above is marked and 5cm below.
The patient then bends forward.
If the distance between them is <20cm then this shows there is a restrictive movement disorder. Helping support SA.
What are the crystals seen in pseudogout? and how do they appear under microscopy?
Calcium pyrophosphate crystals
Positively bifiregent and rhomboid
What are the crystals in gout and how do they appear?
Monosodium urate crystals
Negatively bifiregent, needle shaped
What is the long term treatment of gout?
Allopurinol
- start 3 weeks after attack
- increased every 4 weeks until the target level of urate acid is reached
Febuxostat
- if allopurinol not tolerated
Uricosuric agents
- promote excretion of urate acid
stop use of predisposing factor
- thiazides
- losartan
When investigating gout what additional tests should be done beyond the joint aspiration?
Biochemical screen
- Renal function
- Lipid profile
- glucose levels
- uric acid level
These should be done because of the association between metabolic syndrome and gout.
What should the patient be warned off when starting urate lowering drugs such as allopurinol?
That increased bouts of gout may occur initially and to continue with the treatment. Therefore should be on NSAIDs as well to cover.
What additional management outwith medication should be done for patients suffering with gout?
Lifestyle factors
- loose weight
- reduce alcohol intake - especially beer
- maintain good hydration
- avoid high purine diets - seafood, red meats
- stop thiazides - swap for ACE inhibitors
What blood markers are typically elevated in acute gout?
ESR
CRP
Neutrophils
What clinical findings may be seen on a knee with OA?
Varus deformity
Joint line/ periarticular tenderness
Weakness and wasting of quadriceps
Restricted movement
Bony swellings around joint
What is the most sensitive sign for hip OA?
Pain and restriction of internal rotation of the hip when flexed
What are some risk factors towards septic arthritis?
Immunocompromised
Prosthetic joint
Damaged joint
- RA
- Previous Septic arthritis
IVDU
Diabetes
Localised ulceration
What features of septic arthritis would point towards the infection being a disseminated STI?
Sexually active young person History of STI Migratory arthralgia Polyarthralgia Low grade fever Painful pustular skin lesions
What is the general management for Septic arthritis:
Following investigations, Joint aspiration, bloods.
Sepsis 6:
- IV antibiotics. - 2 weeks IV, 4 weeks oral
Daily aspiration of joint or surgical drainage
If prosthetic then orthopaedics are needed for DIAR or removal
Physiotherapy early on
- passive movement of joint
What is the triad of symptoms seen in reactive arthritis?
what is the management?
Reiter’s syndrome
- urethritis
- arthritis
- conjunctivitis
NSAIDs/ intra articular injections
consider methotrexate if > 6 months
What are two major complications of bisphosphonates?
Acid reflux
- should be avoided in achalasia or strictures due to ulceration affect
Osteonecrosis of the Jaw
- should be withheld during dental work
Atypical Bone fractures
- especially of the hip
What pharmacological management is available for osteoporosis?
Vit D and Calcium supplements
Bisphosphonates
Denosumab
Teriparatide
- PTH recombinant
HRT
What are the T scores ranges?
- 1.5 to -2.5: Osteopenia
- 2.5> : osteoporosis
Where does the DEXA scan usually look at?
Lumbar spin
Hip
Outwith DEXA scan what additional tests do you want to perform in osteoporosis?
- FBC
- TFTs
- Vitamin D
- PTH levels
- Can affect calcium reabsorption• Gonadotrophins
If early onset, especially in males
Good history of previous fractures, and risk factors
what medication is allopurinol contraindicated with?
azathioprine
cause bone marrow suppression
How is Paget disease treated?
Bisphosphonates
Calcitonin
How is Paget’s disease investigated?
Bloods:
- ALP
- C- Telopeptide (bone turnover)
X-ray
- slcerotic bone
Isotope uptake scan
What are the associated symptoms of Ankylosing spondylitis?
A’s
- Apical fibrosis in lungs
- Anterior uveitis
- Aortic regurgitation
- Achilles tendonitis
- AV node block
- Amyloidosis
Outwith Reiter’s syndrome what other clinical finding may point towards reactive arthritis?
dactylitis
What are the red flags of back pain?
<20 years of age, >50 years
worse at night and morning
Associated with systemic illness/ Fever
Weight loss
Previous/ active malignancy
Associated with neurological symptoms
What are the risk factors for recurrence of back pain?
Female Increasing age Pre-existing chronic pain Psychological factors - distress Unemployment
What treatment can be done into vertebral crush fractures?
Vertoplasty
- cement
Kyphoplasty
- balloon
Name some differentials into a swollen joint in a child:
Hemarthrosis
Septic
Juvenile idiopathic arthritis
Reactive arthritis
What Examination do you want to do into a swollen joint?
Assess temperature Look for erythema Check ROM Compare against other knee Look at patient systemically - are they well
What are clinically findings of hands in rheumatoid disease?
Symmetrical
Z deformity of thumb
Prominent ulnar
Swelling of PIPJs and MCPJs
Why might a RA patient have clubbing of fingers?
Interstitial lung disease
methotrexate use
What are some complications of hip joints?
loosening of joint
Septic arthritis
Dislocation
What is a common cardiac manifestation of RA?
Pericarditis
What are the differentials for septic arthritis?
Gout
Haemarthrosis
Cellulitis
Psoriatic arthritis
The fluid aspirated from an infected joint should be sent away for what?
Crystal Microscopy
Gram staining
Cultures
Sensitivities
What is the management of septic arthritis?
IV Flucloxacillin
+/-
IV Gentamicin
or
IV Vancomycin if MRSA or allergic
2 weeks IV, 4 weeks PO
Surgical:
- irragation
- wash out
What are some of the risk factors for OA?
Family history
Obesity
Occupation
Hyperflexibility
Trauma
What are some of the secondary causes of OA?
Intra-articular fracture
Avascular ncesosis
Paget’s disease
Haemochromatosis
What are the surgical interventions that can be done for OA?
Osteotomy - removal
Arthroplasty - joint replacement
Arthrodesis - fixation
What are some non medical interventions into OA?
Lifestyle changes
- weight loss
Insoles - cushioning
Walking aids
Knee braces
TENs machine
Physiotherapy
What is the definition of osteoporosis
Low bone mass
Micro-architectural deterioration
increased risk of fragility fracture
How is osteoporosis differentiated from osteomalacia?
Osteoporosis has normal mineralisation whereas osteomalacia does not
What are the risk factors for osteoporosis:
Menopause
Low calcium
Alcohol
Smoking
Steroid use
Physical inactivity
Hypogonadism in men
What is a screening method prior to DEXA scan for osteoporosis?
Quantitative Ultrasound
What does the T and Z score stand for in Osteoporosis?
T score - Bone density compared against a healthy 30 year old of same gender
Z score - Bone density compared against some of the same age, gender and ethnicity
How many NSAIDs need to be used before TNF alpha is started in the management of Ankylosing spondylitis?
2 NSAID trials.
then move to TNF alphas
